Acupuncture Intake Form Note: Information provided on this form is confidential. It is very important the information given is complete and accurate to assist you properly in your healing process. Please PRINT Name:__________________________________________ Todayʼs Date:____ / _____ / ____ Date of Birth: ____ / _____ /_____ Age: ______ Female ☐ Male☐ Address:__________________________________Apt________City____________________ State:____Zip_________ Occupation_________________Home Phone:_________________ Cell Phone_________________________ Work Phone__________________________ Which is the best number to reach you at during week days?_______________________ Email address: __________________________________(In order to receive FREE weekly health recommendations I need your email. If you don’t like what I have to say, you can always opt out. I promise I will never release your private information to a third party!!) How did you hear about me? ________________________________________________________ Is this your first experience with acupuncture? ☐ Yes ☐ No How do you feel about acupuncture?__________________________________________________ Are you currently pregnant? ☐ Yes ☐ No Are you currently trying to get pregnant? ☐ Yes ☐ No Chief Complaint: _____________________________________________________________ __________________________________________________________________________ How long have you had this condition?____________________________________________ Onset: ☐ Sudden ☐ Gradual What medical diagnosis have you received for this condition?__________________________ __________________________________________________________________________ Symptoms relieved by: ______________________________________________________________ Symptoms worsened by:_____________________________________________________________ Personal Health History ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Seasonal Allergies Indoor Allergies Asthma (childhood) Alopecia Anemia Arthritis (Osteo) Arthritis (Rheumatoid) Bi-polar Disorder Blood Clots Bleeding gums Cancer Type_________________________________When_____________________ Method of Treatment_____________________________________________________ ☐ Congestive Heart Failure ☐ COPD ☐ Colitis ☐ Chronic Fatigue Syndrome ☐ Diabetes Type1 ☐ Type 2☐ ☐ Eczema ☐ Epilepsy ☐ Fibromyalgia ☐ Goiter ☐ Heart condition specify_______________________________________________________ ☐ Hernia (abdominal) ☐ High Blood Pressure ☐ High Cholesterol ☐ Impotence ☐ Lupus ☐ Lymeʼs Disease ☐ Meniereʼs disease ☐ MS ☐ Kidney Stones ☐ Kidney Infection ☐ Obsessive Compulsive Disorder ☐ Osteoporosis/Osteopenia ☐ Parkinsonʼs Disease ☐ Prolapsed Uterus ☐ Prolapsed Bladder ☐ Post Traumatic Stress Disorder ☐ Psoraisis ☐ Scoliosis ☐ Stroke ☐ Systemic Yeast Infection (Candida) ☐ Thyroid disorders: Hyper-active ☐ Hypo-active☐ ☐ Varicose Veins ☐ Vertigo Anything I failed to ask about?_________________________________________________ Muscles, Joints & Bones Do you have pain or tightness?  No affected: ☐ Neck ☐ Upper back (midline) ❍ Right ❍ Left ☐ Low-back ❍ Right ❍ Left ❍ Right ☐ Upper Arm ☐ Elbow ❍ Right ❍ Left ❍ Right ❍ Left The pain is:  Sharp  Superficial  Burning If YES, please check all areas which are ☐ Upper back (shoulder blades) ❍ Right ❍ Left ☐ Mid-back  Yes ☐ Buttocks ❍ Left ❍ Right ☐ Forearm ❍ Right ❍ Left  Dull  Deep  Tingling ☐ Hip ❍ Left ☐ Shoulders (traps) ☐ Shoulder Joint ❍ Right ❍ Left ❍ Right ❍ Left ☐ Thigh ❍ Right ❍ Left ❍ Right ❍ Left ☐ Knee ☐ Calf/shin ❍ Right ❍ Left ❍ Right ❍Left ☐ Wrist ☐ Hand ☐ Finger ☐ Ankle ❍ Right ❍ Left ❍ Right ❍ Left ❍ Right ❍ Left ❍ Right ❍ Left With heat, pain is ☐ worse ☐ better With pressure, pain is ☐ worse ☐ better ☐ Foot ☐ Toe  Aching  Numbing ☐ Comes & Goes ☐ Constant  Shooting ☐ Stabbing With cold, pain is ☐ worse ☐ better Pain worse in ☐ am ☐ pm I have: (check all that apply)  Swollen joints  Arthritis/joint pain  Tendonitis  Bone pain  Muscle cramping  Muscle pain  Repetitive Strain Injury  Fractured Bone(s): Where?____________________________ Please indicate on the figures your affected areas! X marks the spot(s) Exercise & Energy How is your energy? _______________________________________________________________________ What time of day is your energy: Highest?_________________________ Lowest? ____________________________ Do you fatigue easily ?________________ What kind of exercise do you do ? ____________________________________________ How often do you exercise ?_________________________________________________ Emotions & Sleep How do you feel emotionally? ______________________________________________ __________________________________________________________________________________ Do you have (check all that apply): ☐ panic attacks ☐ depression ☐ difficulty concentrating ☐ anxiety ☐ short temper ☐ poor memory ☐ chronic worry How do you hold stress?_________________________________________________________ How do you relax? ______________________________________________________________ How do you feel about your work? ________________________________________________ How many hours do you sleep at night? ________________ Do you have difficulties with (check all that apply): ☐ falling asleep ☐ awakening too early ☐ awakening at _________ am/pm ☐ dream disturbed sleep Gastrointestinal Symptoms ☐ belching ☐ nausea ☐ acid reflux ☐ vomiting ☐ indigestion ☐ pain after eating ☐ bloating ☐ hernia ☐ heart burn Bowel Movements How often? _____________time(s)/day _________________ days/week I have (check all that apply): ☐ constipation ☐ diarrhea ☐ burning sensation ☐ hard stool ☐ gas ☐ hemorrhoids ☐ blood in stool ☐ irregular bowel movements ☐ itchiness ☐ mucous in stool ☐ loose stools ☐ painful movement Urinary Urination: How often?__________times/day Color: ☐ pale yellow ☐ dark yellow I have (check all that apply): ☐ frequent urination ☐ painful urination ☐ dribbling ☐ difficulty starting stream ☐ urinary tract infections ☐ kidney stones Female GUT At what age did you first menstruate? __________ Number of days between cycles _______ Number of days you bleed: __________ Color: _________________________ I have: (check all that apply) ☐Irregular menstruation ☐Heavy flow ☐Light flow ☐ No flow ☐Clots ☐Vaginal itching/burning ☐Spotting between periods ☐Discomfort/ Dysmenorrhea ☐Mid Cycle Spotting/ Pain Vaginal discharge? ☐ No Color:______________________ ☐Yes Number of live births:__________ Number of miscarriages or abortions: _____________ Male GUT I have: (check all that apply)  Prostatitis  Enlarged Prostate  Impotence  Blood/mucous discharge  Libido  EDS Eyes, Ears, Nose, Throat, & Head Do you smoke?  No  Yes _________ per day, for ______ years I have: (check all that apply)         Frequent colds  Chronic runny nose  Frequent sore throat Chronic cough  Coughing blood  Cough up mucous Pain on inhaling  Asthma  Nose bleeds Painful/red eyes  Poor vision  Spots/floaters Dizziness  Cold sores  Bleeding gums Dry mouth  Ear pain  Ringing in ears Clogged/popping in ears  Shortness of breath on exertion/at rest Frequent headaches/migraines Cardiovascular I have: (check all that apply)  Chest pain  Palpitation  Phlebitis  Cold hands and feet  Poor circulation  Hypertension  Breathlessness  Varicose veins  Irregular heart beat  Hypotension Skin & Hair I have: (check all that apply)  Dry skin  Eczema  Skin rashes  Hives  Itching  Hair loss  Acne  Premature graying